Community Conversation: What We Now Know About Coronavirus

– Welcome to “Community Conversations.” My name is Luke Vorgolis, I am the Corporate Communications Director here at Atlantic Health System And today I would like to welcome back, for his second Community Conversation, Doctor Jason Kessler He is the Section Chief of Infectious Disease at Atlantic Health Systems Morristown Medical Center Doctor Kessler welcome back – Thank you Luke Glad to be back – Yeah we didn’t scare you away last time So you’re back for another one Before we jump into our conversation, I’ll give our folks, who may be joining us for the first time a little bit of background as to how this works Doctor Kessler and I will chat for a little bit We will, try to incorporate some questions from our audience And of course if you have anything you want to add as we go along, please feel free to add that into the comment thread, alongside the video We’ll try to loop in some of those comments as we move along as well This will be seen as you are now live on Facebook However we are also sharing it in some other platforms Go to our website, AtlanticHealth.org, and you’ll see a link to all of our Community Conversations there You can find it, through our various social media accounts including LinkedIn And for those of you who are more comfortable watching on television, News 12 Plus airs us on weekends, 8:30 to 9 on Saturday’s and Sunday’s So, that’s kind of the gist of how we do this process And Doctor Kessler, like I said, welcome back The topic, or the title I should say of this, is basically we need to know about, what you need to know now about coronavirus And so what we wanted to do was, acknowledging the fact that you and I last spoke in this format, I think it was April, the second week of April Right around April 16th or the third week of April, somewhere around there But a lot has happened between now and that point And so, I wanna start first with a question of just, as we reflect back on what we knew then versus what we know now, how much in your opinion has changed? Do you think we got a lot of this stuff in terms of our knowledge of COVID-19 right early on? Or how much have we learned? In a broad sense, and then we’ll drill down What do you think? – Yeah, so I think that, the big message that I would like folks to take away from today’s conversation is that, we are still learning a lot about COVID-19 We have just started, the learning process A lot of what we were doing, saying, recommending, four to six to eight to ten weeks ago, we’re now saying, slightly different things Or maybe even, completely 180 degrees, the opposite thing of what we were saying at that time So, the process of science, and the process of medicine, and the process of clinical care, and epidemiology and public health is a process that is constantly undergoing iteration Constantly undergoing change And, that’s a good thing and a bad thing, in some cases Because sometimes that can create confusion Because one thing that we say today may not necessarily hold true tomorrow as the science changes and as facts evolve And as the truth comes to light so-to-speak And I think that’s the big message, is that we’re still learning We are gonna make mistakes, and we are gonna say things that we’re gonna have to back track on somewhat so-to-speak But all of that being said, we are trying to use both at Atlantic Health and I think across the country and across the world, the best methods available to us And trying to expand our knowledge basis quickly, and as efficiently as we can – Let’s start with some of the public health initiatives I think that, and they are things that we continue to talk about now, so I’ve probably answered my own question to an extend But I think it’s worth reinforcing Those early public health things, that guidance that we provided for folks, the masking, the hand washing, things along those lines In your opinion, are those tactics still as relevant today as they were? – Yes I think the public health messaging and the public health measures that we’ve put into place, at least since early April, are still very relevant And are still the, critically the most important things that we can do as individuals, as community members, as citizens, to prevent and mitigate the spread and impact of COVID-19 And they really come down to a few things Keeping social distancing in place, whether you’re indoors or out of doors Washing your hands regularly Keeping very close attention to your cough hygiene, so coughing into your sleeve or a tissue And now we’ve really included, since we last spoke, the benefits of wearing masks or facial coverings – In fact when you and I last chatted, this was actually before the universal masking concept had really become as widespread as it was So that very much is a newer concept – Yeah And I think that there is a growing body of evidence,

that mask wearing by the general public, as well as health care workers, which we had always been doing, may have a significant impact on reducing the spread of coronavirus It’s not going to reduce it to zero Masks are not a magic bullet in any sense And the evidence is not definitive or conclusive But I think that there is plenty of evidence on a population level, on a basic science level, that they may be some impact even for the public to wear simple cloth facial coverings And, not all coverings are the same, and not all masks are the same There’s a gradation of benefit, and a gradation of utility And they range from, you know the medical respirators that doctors and nurses and other staff members use in the hospital The N95 – N95, yep, things like that – And they range all the way down to something like a simple cloth covering – Sort of like what we got – Yeah And so they’re not all the same, and I think everyone recognizes that And, some offer a greater degree of protection, to both the wearer and to the public around the wearer But, I think that there is a growing body of evidence that you know, masking can reduce the spread of COVID-19 And that is a change, a very significant change from what we were saying at the very earliest parts of the epidemic – What about, in terms of how we are caring for those who have it? And I know this is tied into another discussion that I wanna have today as well, about, changing numbers and figures and things that we’re seeing in other parts of the country and how they relate to what we have here But, how about how we are caring for those? What have we learned about the virus and the way we care for people now that is different from where we were in the early stages of this? – Well I think we’ve learned a tremendous amount in the area of therapeutics, and the area of clinical care of patients with COVID-19 as well What we were doing in the hospital, even out of the hospital, 10, 12 weeks ago is vastly different than what we’re doing now Nowadays, we have a patient that comes into the hospital, they are being managed almost in a completely different way in some respects They’re getting different kinds of medications than they were 12 weeks ago different sorts of additional therapeutics or different kinds of supportive care than they would be potentially throughout– – Proning was something I heard, more patients are now being put on their stomach actually – Right, so, things like proning, different types of strategies to use the mechanical ventilators, if and when patients develop critical illness And, in particular some of the medications, I think there’s been a lot of attention paid to that That some of the medications that people have been using or were using and continue to use have changed quite dramatically over the span of the last 12 weeks – How is that reflective of how infectious diseases are learned about and managed period? COVID-19 is not the first infectious disease that we as a country, as a planet have faced So, are there similarities with how this process has moved for us, as with other things? And maybe for some folks out there wondering if there will ever be an end to this type of effort Maybe there is a positive there in how this ideation has moved forward – Yeah I think it’s very, similar Obviously there’s dramatic differences but it overall if you look at a very high level view, the response to the COVID epidemic and the manner in which we’ve learned about it and responded to it, is very similar to the manner in which we’ve learned about and responded to other serious epidemics like the H1N1 epidemic in 2009 The West African Ebola outbreak in 2014 into 2015 In both of those cases for example, you know we learned a great deal Whereas, initially we didn’t know what really would work And we tried you know, to learn as quickly as we could By the end, or you know, at some point after that, we’ve had both a vaccine, as well as novel therapeutics, and a care strategy that actually saved lives So, I see the response to COVID-19 in a very similar light as I see our response, our global response, to some of these other pathogens of concern, that were on everybody’s mind Not too long ago – We have talked as a system, and I know that some of our leaders have talked about this in various media interviews and things along those lines But we talk about, the peak of cases that we had here as a system as a state really, in that, second to third week of April area We are a far cry, from that now But, as we see some of what’s happening in other states, in recent times, I think there is a lot of renewed interest in how we are measuring the spread of the virus, and what’s happening here

In the hopes that we don’t then fall back into where some of those states are I have seen recently that the spread of the disease being measured with a 1.1 number, 1.03 number, I’ve seen a couple different things over the last couple of days Can you explain for folks who may be seeing that same information out of the governors office, and are having a hard time interpreting what that means relative to the facts on the ground? How do you measure the spread of an infectious disease like this? And what does that number mean, that 1 point whatever it may be? – So we as epidemiologists, I was trained as a epidemiologist in addition to as a infectious disease physician, we use, two main descriptors to describe the transmission of a communicable disease, like COVID-19 One is the reproductive number, which I think people are aware of or have heard of It’s the R naught or R zero And basically what that number refers to, is the number of secondary infections that an individual usually will pass on So– – So them plus whoever gets it from them? – Exactly And usually, the classical thinking is, if that number is two or greater, there is going to be continued epidemic spread within a community So if I have COVID-19 for instance, and the R naught in the community, or at the time is two or greater, I’m going to spread it to at least two other people And I think that the studies that were done, early on in the epidemic suggested that you know there’s variation, but the R naught or the R zero for COVID was certainly greater than two But for example, as a contrast, something like measles which is one of the most transmissible diseases, may have in some cases an R naught greater than 10 So– – Okay, so relatively speaking it’s a far cry from that – Exactly But the interesting thing about the reproductive number is that it is dynamic, meaning it changes And it changes in response to human activity, and it changes in response to human behavior, and it changes in response to interventions that we may put into place So if we put into place, a social distancing policy or practice, and it’s widespread, the R naught will decrease Similarly if we have a– – I was gonna say, what gets it to go up then? – Yeah, if we decide that, we’re not going to do that anymore for whatever reason, and people go back to doing the things that they were doing in December or November of 2019, the R naught will go back up again So the R naught, the reproductive number, is dependent both on the virus itself or the pathogen itself its characteristics and how it behaves But it’s also, in large part determined by what we do in response to it The other number that’s thrown around some in the late press but, many people may not be as familiar with it as the dispersion factor And that really gets at the issue that, not everyone transmits the virus equally There are some people who seem to transmit it, much more widespread, the quote unquote super spreaders And there are other people that don’t seem to transmit it at all, or very little – Do we know why that is? Why some individuals may spread it more than others? – Yeah, I think it has some to do with the person And it has some maybe to do with the virus But probably, it has the most to do with the setting, and the situation, and the behavior of the individual So if you have somebody who is in the earliest phases of their illness They are not practicing social distancing, they are not practicing good hand hygiene, and they’re not practicing face coverings, and they go to an indoor setting like a concert – Concert – Or a sporting event – Sporting event, where there are other susceptible people, that has a high chance that there’s going to be a lot of people infected And that’s gonna have a high dispersion Whereas if you took the same person, at the same stage in their illness, but instead they were wearing a mask, they weren’t going to an indoor, crowded activity – Outside of– – Or you know outside just with their family Maybe nobody gets the infection from that individual So I think a lot of it has to do with the context and the setting that you find yourself in And where you are in the illness – I wanna mix in a couple questions that we’ve gotten from folks ‘Cause, again we wanna thank everybody who took some time to send in some questions for us So doctor if you will We’ve got a couple that all kind of fall into a similar sort of zone And they’re topics we’ve talked about in the past so I wanna take this opportunity to refresh our knowledge and see where we are on them And Carla, has emailed us wondering (clears throat) excuse me, as a grandparent, who maybe has not seen their grandchild in quite some time,

is it now safe to do so? And maybe that’s more of a question that requires less of a physiology answer than in more of a behavioral one But in your opinion, under what circumstances is it safe for grandparents to see their grandkids? – Well you know I think every case is different It’s hard to make a one size fits all kind of policy, or recommendation for a question like that when it comes to an individuals risk Of anything, of driving in a car, or take an airplane, or crossing the street, or visiting your grandchildren when you know the COVID epidemic is present But I think the things that should go into ones consideration are have you or your family been following and complying with the recommendations of the jurisdiction in which you live? Usually that means, you know social distancing, and not going to indoor crowded events or areas Are you, as an older person, particularly susceptible to COVID-19? If you got infected would you be at high risk for a very poor outcome? Now obviously, age is the greatest predictor for bad outcomes in COVID-19 but not all 70-year-olds or 80-year-olds or 90-year-olds are the same I know some, I’ve seen some 90-year-olds in the hospital I’m like, they look like they’re 75 if not 60 – We should all be so lucky I guess – But then again there are others that, you know younger people, who have very significant and serious medical conditions that would put them at very high risk for a bad outcome So, these all need to be balanced together when making a decision like that But I think that, in general, and again this is a general comment Where we find ourselves currently, so we’re talking about the Northeast, metropolitan area We right now are in a situation where we have fairly low community spread Nothing compared to right now, what’s going on in other parts of the country – Right – And as such, I think that the risks are certainly lower than they were you know 12 weeks ago And so, if you’re a grandparent, or you’re a parent of a child who wants to see their grandparent, and you’re healthy, and you’ve been following the precautions and you’ve been socially distancing, and your grandmother or grandfather is in, you know, generally a well person and is not has severe chronic medical conditions Then I do think, as long as people are following the social distancing recommendations and the masking recommendations, then it is okay to visit with their family – All right – And they should, because psychological well-being, both for young people– – Carla – Carla, as well as the grandparents themselves is important And so yeah, with care and with thoughtfulness, I think it is appropriate – Susan, is going to have spinal surgery soon And she wants to know, should she be wearing a mask when she’s in the hospital, and will healthcare workers be wearing masks as well? What can we tell Susan about the way we’re delivering care right now during what’s going on? – So I think that is one of the very interesting but unfortunate secondary effects of the COVID-19 epidemic, both in New Jersey and New York and in our area as well as other parts of the country In that, people delayed the care that they needed Some of it was rightly so, and some of it was because they were scared And we’ve learned a tremendous amount about how to keep people safe while taking care of them in the hospital And so, at Atlantic Health and I know in other hospital systems around the country, many different procedures have been put into place to ensure that people are cared for safely So for instance, I can speak knowledgeably on our system in our hospital and what we do, patients who are coming in for procedures or for surgeries, you know they are gonna be tested for COVID-19 To make sure that they don’t have asymptomatic infection ‘Cause we know that patients who have COVID-19, compared to patients who do not have COVID-19 have poorer surgical outcomes So we don’t want to be doing non emergent surgery on a patient who has COVID-19 We’d like to delay it if we can Sometimes that’s not possible, sometimes, they’re having a heart attack or they had a severe trauma and they absolutely must have their procedure They absolutely must get care at that moment What do we do about those folks? Well– Our healthcare work force is, you know has a standard universal masking policy in the hospital So all of our healthcare workers are wearing masks All of our healthcare workers have been instructed in appropriate hand hygiene

And so, they are looking out for the best interests of our patients And any patients that remain in our hospitals who do have COVID-19 are geographically separated from any patient that’s coming into the hospital for another reason So, the chances of cross contamination are extremely extremely small – Thank you doctor And thank you Susan for submitting that question Ryan has a question on Facebook Can you, in terms of the age groups, in relation to people being carriers and how they’re impacted, how this effects people differently You talked a little bit about age being a precursor for how you deal with COVID What are we seeing in terms of various age groups? Let’s start with our younger folks who were very much in the news lately as far as the spread of this But, let’s start with our younger folks and then move our way up What do we now know about how COVID is contracted by those folks, and how it effects them? – Well I think there’s still a lot of information that we need to learn about how it effects, especially the youngest of our population – Like school aged children – School aged kids I think we don’t really know, exactly what the differences are between school aged children and older children or older adults And how they are infected or not infected Or how susceptible they may be or not susceptible they may be I think you know for children, generally speaking, they tend to have less severe disease They’re at much lower risk of severe outcomes like death or severe morbidity than older folks I think that’s, pretty clear, based on our experience But, young people can die in very rare cases, of COVID-19 So it is not something that we should be taking lightly So it still can effect anyone, severely They’ll certainly much less likely in certain cases You know I think what we’ve seen, you know during our experience during the first outbreak or first surge, was you know there was a lot of tension and focus, rightly so, paid on the older populations And those were the people that were really suffering the greatest morbidity and mortality But if we look back, at the global picture In New York and in New Jersey, the places that were first hit hardest by COVID-19, the majority of people who were diagnosed with COVID-19 were under the age of 50 So young people contracted, at least an equal if not greater rate than older folks And the reason of that is is because they are, the young people are the ones, when I say young I’m not, I don’t know if I can include myself in that, but – For anyone’s sake– – Young people are the ones that are out in the communities They’re working, they’re in closed offices, they’re interacting socially So they’re at much higher risk for that reason When you look at the people who suffered the most who had the most severe outcomes of COVID-19, that is when you start talking about people who are living in nursing homes, people who have very severe chronic medical conditions – The older– – People who are older But, what we’re seeing now in other regions of the country that are now experiencing what we experienced, three months ago, or two to three months ago, is not that different I mean in Florida for instance, or in Texas or Arizona, the vast majority, or at least a majority of people that are contracting COVID-19, are people under the age of 50 – Brian wants to know, and I think you actually gave the answer to this a short while ago, so let’s repeat it for Brian, so we can The separation of patients when they’re being treated Those with COVID and those without That is something we are doing, at our facilities here at Atlantic Health System, yes? – Correct, that is something that we instituted very very early on And was probably one of the key interventions that our leadership implemented that was tremendously successful in reducing the potential spread within a healthcare facility And we continue to do that and we will continue to do that moving forward – So Brian there you are Molly wants to know, and this is the question that is so difficult to predict You know, and so I think everybody will understand if we’re not able to put too fine a point on it But, it’s the question on everybody’s lips in New Jersey at least Molly wants to know, what are the chances for a second wave of COVID-19 here in New Jer– And she– New Jersey specifically, but just a second wave? – Sure – What are your thoughts? – I mean I think, the bottom line is, I would be surprised, very surprised, if we don’t have some increase in our incidents of COVID-19 in some point before a vaccine becomes available to us I don’t believe it’s going to look exactly like what we experienced over the last three months I think it’s going to be, somewhat different

in its scope and its intensity But I do think we should be expecting to see, an increased case load in New Jersey, in some point in– – Some of that’s up to us though right? I mean I think there is a bit of, whereas in the beginning maybe I don’t think everybody fully knew enough to say that that was in our hands completely We know that, for the most part now right? – Exactly And I think that’s why it’s going to be different, as far as the number of cases and the intensity of the cases I think, we’re doing a lot of things differently than we were in the beginning of March You know, most people are socially distancing Most people are washing their hands regularly or paying much more attention than they were in March for things of that nature And I think most people, generally speaking, are wearing masks when they can’t socially distance So all of those things are very very different to our behaviors, the way that we were acting, and conducting ourselves you know in early March and mid March when this all really started in our area So I do think it’s gonna change what we see, should we start seeing an increased transmission in our community again – Daphne want’s to know, and this hearkens back to the idea of being in an indoor facility versus an outdoor space If you know that particulate respiratory droplets, things along those lines, are our main method of transmission here Can you talk about, what the implications are when you are inside versus outside? Is it just, that much harder for respiratory droplets and things of that nature, to transmit to another person when you are outside? What is it about inside and outside that makes such a big difference? – Well I mean I think it’s the, you know it’s very complicated, and I’m not– – You know we don’t need to dive too deep into the molecular biology, but – I’m not a expert in airflow dynamics I mean there are people who spend their entire lives dissecting and trying to understand the dynamics and physics of airflow within buildings and in the outdoor setting But, you can imagine, in the very simplistic terms, if you put an amount of virus in a contained space the concentration of that virus is going to be greater, than if you put it in a much much larger space like outside – Sure – So, and the wind patterns that are outside tend to disperse those particles around an individual much quicker than, inside where the air flow may be much more constrictive or restrictive So– I think that has a lot to do with why indoor transmission is so much more, or so much bigger of a challenge to get our hands around Compared to outdoor activities And, you know and I think that bears out in that we haven’t seen large super spreader events stemming from outdoor activities, that were clearly associated with outdoor activity Sometimes it can be Because there are situations where people aren’t socially distancing, and are you know maintaining very close space even in the outside setting And so there is still potential for transmission, but, I do think it is much less of a risk – We have time for one more And I wanna ask you, something that I think is impactful, because it’s very reflective of where we were versus where we are now There has been a precipitous drop in many cases, in I guess what some folks are calling mortality of the disease, the death rate of the disease And I think it has lead some to believe that perhaps COVID-19 is just either not as dangerous as it was, or you know, maybe losing steam in some way Can you articulate for everybody, I guess in a broad sense, is COVID-19 still very much a dangerous deadly condition? And if so, what is it that is causing the death rate to drop? If I’m articulating this properly And if I’m not, please correct me if I’m– – Yeah No I think a lot of people have that question on their minds and it seems counterintuitive compared to what we saw early on in the epidemic And what I can tell you is that COVID-19, SARS-CoV2 the virus that causes COVID-19, is still a very serious virus And COVID-19 is still a very serious illness Again– In the majority of individuals who are infected, they are going to recover And they are not going to be hospitalized They are not going to be in the ICU, and they are not going to be on a ventilator However, SARS-CoV2, COVID-19 is a very transmissible infection Meaning you can give it to a lot of people in a very short span of time And we have a highly susceptible population Studies that are now being done suggest that in large metropolitan areas that experience the first wave,

may be nine to 10 percent of the total population was infected That means that, 90 to 95 percent of us are still potentially susceptible to getting this – Right – And if you take the population of New York, or New Jersey, or the United States for instance, and just say, “well the death rate’s only one percent, “or even less than one percent.” Well, one percent of 300 million is a lot of people – Lot of people – So if you take a small percentage of a big number you’re gonna get a big number – Right – And so it’s still a very big concern And I think people really do need to take it very very seriously And continue to take it seriously That being said, I think there are several explanations as to why the case fatality rate continues to either stay stable or decrease compared to what we saw And I think that has to do a lot with all of the behaviors and interventions that we have put into place We know, and people know, the most highly susceptible individuals are older people with chronic medical conditions And I think if you asked the average older person with a chronic medical condition, “what are you doing now, compared to “what you were doing – (laughs) Actually it’s quite different – “February 1st 2020?” – I would imagine, the answer to that question is remarkably different – Sure – So, the people who are most susceptible are aware, for the most part, that they are the most susceptible And they are taking, I would imagine, generally speaking, every precaution that they can to prevent them from getting it And what we’re seeing now is that, you know, younger folks who tend to have a little bit of magical thinking, that nothing can hurt them And that may be true to some extent But, you know we’re seeing many more of them get infected because they may not be complying as rigorously with some of the precautions that are recommended So, we’re seeing cases increase We’re seeing fatalities sort of stay the same, or even decrease in some parts of the country And I think again, that has a lot to do with what people are doing and their perception of their own risk But the point is that, even if you’re young, and you think you’re healthy, there are young healthy people who have died of this disease – Yeah – Maybe it’s not, tens of thousands of them But there are cases And, there are simple things that you can do, to prevent the spread of this disease and to protect yourself – And those are amplified by the fact that, we now know so much more than we knew before So Doctor Kessler again, thank you for comin’ back – My pleasure – And for joining us again for this conversation I know there are a couple conversations, couple questions rather, that we were not able to get to through our conversation here But we will try to get you answers through our social media platforms And of course, please feel free to reach out to us if you any additional ones So, for Doctor Kessler and for myself, thank you so much for joining us on our Community Conversation And we will see you next time